Objectives: Our aim was to identify prognostic variables for long-term postoperative survival in trimodality management of malignant pleural mesothelioma. Methods: From 1980 to 1997, 183 patients underwent extrapleural pneumonectomy followed by adjuvant chemotherapy and radiotherapy. Results: Forty-three women and 140 men (age range 31-76 years) had a median follow-up of 13 months. The perioperative mortality rate was 3.8% (7 deaths) and the morbidity, 50%. Survival in the 176 remaining patients was 38% at 2 years and 15% at 5 years (median 19 months). Univariate analysis identified 3 prognostic variables associated with improved survival: epithelial cell type (52% 2-year survival, 21% 5-year survival, 26-month median survival; P = .0001), negative resection margins (44% at 2 years, 25% at 5 years, median 23 months; P = .02), and extrapleural nodes without metastases (42 % at 2 years, 17% at 5 years, median 21 months; P = .004). Using the Cox proportional hazards, the relative risk of death was calculated for nonepithelial cell type (OR 3.0, CI 2.0-4.5; P < .0001), positive resection margins (OR 1.7, CI 1.2-2.6; P = .0082), and metastatic extrapleural nodes (OR 2.0, CI 1.3-3.2; P = .0026). Thirty-one patients with 3 positive variables had the best survival (68% 2-year survival, 46% 5-year survival, median 51 months; P = .013). A previously published staging system using these variables stratified survival (P < .05). Conclusions: (1) Multimodality therapy including extrapleural pneumonectomy is feasible in selected patients with malignant pleural mesotheliomas, (2) pre-resectional evaluation of extrapleural nodes may select patients for radical therapy, (3) microscopic resection margins affect long-term survival, highlighting the need for further investigation of locoregional control, and (4) patients with epithelial, margin-negative, extrapleural node-negative resection had extended survival.
Sugarbaker, D. J., Flores, R. M., Jaklitsch, M. T., Richards, W. G., Strauss, G. M., Corson, J. M., … Faber, L. P. (1999). Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients. Journal of Thoracic and Cardiovascular Surgery, 117(1), 54–65. https://doi.org/10.1016/S0022-5223(99)70469-1